There is a Haitian proverb which goes “deye mon, gen mon” – beyond the mountains there are mountains. Consider Haiti’s history for a moment – tainted by slavery, witchcraft, civil unrest, disease, and natural disaster – and its meaning begins to be realised. I arrived in the capital, Port-au-Prince as a medical volunteer two weeks after the confirmation of the first case of cholera, which a fortnight later had caused over 20,000 hospital admissions and around a thousand deaths. As I descended over the lush, green mountains of Haiti, I did not comprehend just how steep and foreboding the challenges facing this country really are.
Haiti first entered my consciousness when reading Paul Farmer’s accounts of working in the country over many years. They give an insight into the epidemiology of infectious diseases such as HIV and multi-drug resistant TB that have ravaged Haiti’s population since their emergence. Other literature about these diseases paint an ugly picture of Haiti, making it a key suspect in the crime of introducing HIV to the USA (when in fact the opposite is likely to be true), and blaming the spread of drug resistance on “beliefs in sorcery causing patients to abandon biomedical therapy.” Using the stories of individuals, Farmer shows that in fact it is poverty and inequality within this – the Western world’s poorest country – that leaves it so vulnerable to infection and the spread of disease.
Nothing demonstrated the fragility of Haiti more acutely than the earthquake of January 2010. A year later, an estimated 800,000 people still live in spontaneous shelters, lacking employment, food, water, and basic sanitation. Haiti’s health sector was precarious before the earthquake hit, with only 1 nurse and 3 physicians per 10,000 people. But its further depletion has been catastrophic. The minister of health, Alex Larson, says that the lack of human resources is now Haiti’s biggest crisis. In light of this, the emergence of a national cholera epidemic in October 2010 filled Haitian and international health communities with dread.
Before leaving for Haiti I asked a local pharmacy for oral rehydration salts “for Haiti,” hoping for a donation or a discount to fill my 20kg hold-bag. It was hard not to laugh when I was handed a pack of six and asked, “will this be enough?” In a country where most people do not have access to clean water or sanitation, cholera had already been spreading fast. During the two weeks I was in the country the recorded number of deaths doubled. And recorded numbers unfortunately do not capture the full extent of the disease, as cholera victims frequently go unseen and uncounted. The new onslaught of a disease that has killed so many was filling Haitians with fear. I was shocked to hear a lady in Port au Prince tell me she would rather contract HIV – a lifelong infection with multiple complications – than cholera. But, as I tried to tell health workers over and over again, responding to individual cases of cholera is relatively straightforward. It’s preventable through using soap and clean drinking water and treatable with a simple salty drink (ORS). The World Health Organisation estimate that 80% of cholera can be treated by drinking this mixture alone and that, if treated properly, fatality rates should remain below 1%.
So why, with such easy and cheap treatment, is this disease causing so much fear in Haiti, and a death rate of more than three times the WHO’s projections? I gained some insight into this lady’s dread of the disease during night-shifts in “choleraville” – the affectionate name we gave the isolation zone set up in the grounds of the general hospital in Hinche, three hours drive north of Port au Prince. It was raining and dark when I arrived at the two tents; the power had cut out again. I peered in to see around eighty patients lying semi-naked in the remnants of disposable surgical gowns on drenched soiled camp beds, buckets of waste in the mud by their sides. A further thirty or so lay in an old chapel with chickens wandering in and out, pecking around the rubbish strewn grass among broken needles and soiled bedclothes. The drips hanging to the walls of the tents were mostly dry, their lines now filled with clotted blood. The “pharmacy” (a sodden cardboard box in a corner) was being used as a seat for one of the two nurses on duty. The other one was nowhere to be seen.
The “nurses” it turned out were actually mostly auxiliary staff, recruited hurriedly after the earthquake destroyed a segment of Haiti’s already diminishing workforce. They had received little training, and often went unpaid for weeks on end. With no time off from domestic duties to rest during the day, it was little wonder they expected to sleep during a night shift responsible for critically ill patients. But what shocked me most was their apparent indifference to the suffering around them. I was angry and amazed to find small babies left naked, lying in their own faeces, and elderly patients who were too weak to lift a bottle to their mouth – followed by a shrug of the shoulders when I returned the next night to find their empty beds.
But as I spent time with the nurses on my shift, I realised they likely felt powerless to change the fate of the sick, exhausted after working night after night and demoralised from seeing so much death. They were as scared of cholera as the patients were, unwilling to touch them to change their soiled clothes or lift a bottle to their dry lips. I worked just five nights in choleraville and felt disturbed, frustrated, and then relieved when it was all over. But for them, this was normal working life. They had seen patient after patient die unnecessarily when the water supply ran out or no one could find enough intravenous kits to get vital life-saving access for fluid. Perhaps their sheer frustration had become indifference.
I set to work, hoping that seeing me willing to hold an old lady’s head so she could drink, and clean a screaming child when they had soiled themselves for the fourth time, would move them to action. And gradually, it started to sink in. One of the nurses pointed to a fluid bottle when it was empty, asking, “Should I change it?” The next time she took the initiative to change it herself and started to see results – and looked pleased and surprised when patients were still alive in the morning. As I had enthusiastically tried to communicate to these blankly unresponsive faces when I arrived, treating cholera is easy. And gradually I began to see a flicker of satisfaction and amusement in their tired eyes – when severe dehydration was turned around in a matter of hours; when listless babies with sunken eyes, started to sit up and suck on their bottles of cherry flavoured diarolyte; and when a stone cold, almost pulseless young man came round, stood up, told me he had a wet back and vomited on my shoes.
As I left behind the mountains of Haiti, with its soaring number of cholera cases and with troublesome elections around the corner, I asked myself what hope is there for this country? Indeed at first glimpse the future looks grim. Before leaving Port-au-Prince, which had until then been declared cholera-free, I opened a baby’s nappy to the unmistakable stench of the disease. As so many had feared, the disease has since gripped the capital, sending further victims to the mass graves dug the year before. Having seen a glimpse of the reality of a threadbare health service managing the beginnings of a deadly epidemic, I can only imagine what conditions are now like as the affected numbers have continued to increase.
But wherever you look in Haiti there is hope – in the smiles of Haitian children dancing in their makeshift streets, in the willing volunteers spending thankless hours still working on the post-earthquake and cholera response, in the billions of dollars donated not only by international governments but individuals and celebrities moved by the cause. But as Minister of Health Larson insists, the main thrust of hope and effort must remain in the strengthening and improvement of Haiti’s own health sector. In only five nights I saw deeply discouraged nurses learn to take initiative. They started noticing when drips ran dry and then they started changing them. They looked pleased when patients thanked them, surprised when they were still there the following night and amazed at the ‘Lazarus cases’ that occurred. They became empowered to make a difference themselves in saving and improving the lives of their own people rather than relying on outside help.
Currently the health system in Haiti is not only propped up from the outside but in some places entirely replaced by international NGOs. This leads to a reliance on external donations and volunteers. While in the short term this may be a necessity, over time it will likely prove to be both unsustainable and disempowering to the existing talented and passionate Haitian medical workforce. Health NGOs, like those working in other sectors, must remember that their long term goal must be an independent and strengthened health sector which can stand up to whatever hardships might lie beyond the mountains in Haiti.
Rachel Wake is an SHO working in London